By: Pamela Moore, MS, RHIA, CCS, CRC
Professional Services Project Manager
Streamline Health

The Greek philosopher Socrates once said, ‘The secret of change is to focus all of your energy not on fighting the old, but on building the new.’ Change isn’t easy—particularly in healthcare where it can have a cascading effect on people, processes, and revenue.

Socrates was right. There’s no sense in looking backwards. However, unlike many changes in healthcare, there’s one recent change that should actually make physicians’ lives a little easier: the new Evaluation and Management (E/M) guidelines for Office Services that took effect January 1, 2021.

Understanding and Adjusting to the 2021 E/M changes for Office Services

“What’s exciting about this change is that it should enable providers to focus less on unnecessary documentation and more on direct patient care.”

In the coding world, new E/M guidelines are epic. That’s because it has been nearly 25 years since we’ve seen any changes. That’s a long time—especially in an industry where change tends to be the only constant. Coders and providers alike had frequently lamented the burdensome requirements of the 1995 and 1997 E/M guidelines as well as the fact that these guidelines never seemed to reflect the realities of complex clinical care. Now, it’s time to let go of old documentation habits and embrace a new patient-centered process. The new E/M Guidelines for Office Visits enable this.

2021 E/M changes: The nitty gritty

Per the 2021 E/M guidelines, providers can now use Time or Medical Decision Making (MDM) to select an E/M level for codes 99202-99215. This is a fairly significant departure from how it has always been done—a process that required providers to tediously count bullet points and document a whole host of elements related to history and exam.

What’s exciting about this change is that it should enable providers to focus less on unnecessary and irrelevant documentation and more on direct patient care. It should also reduce ‘note bloat’ that has plagued the industry since the widespread adoption of EHRs began. That’s because clinicians no longer need to re-record elements of history and physical exam when there is evidence that the information has been reviewed and updated.

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Here’s a summary of what else is new in 2021:

1. Time includes the total time spent by the provider on the day of the encounter—not just face-to-face time. (Note: Counseling and/or coordination of care do not need to dominate the visit in order to select an E/M code based on time). Total time now includes the following activities when performed by a physician or other qualified healthcare provider:

  • Preparing to see the patient (e.g., reviewing tests or obtaining and/or reviewing a separately-obtained history)
  • Performing a medically-necessary, appropriate exam and/or evaluation
  • Counseling and educating the patient/family/caregiver
  • Ordering medications, tests, or procedures
  • Referring and communicating with other healthcare professionals (when not reported separately)
  • Documenting clinical information in the patient’s record
  • Independently interpreting results (when not reported separately)
  • Communicating results to the patient/family/caregiver
  • Coordinating care (when not reported separately)

Also note that the time thresholds associated with each code will change as follows:

CPT code Time threshold in 2020 Time threshold in 2021
99202 20 minutes 15-29 minutes
99203 30 minutes 30-44 minutes
99204 45 minutes 45-59 minutes
99205 60 minutes 60-74 minutes
99211 5 minutes —*
99212 10 minutes 10-19 minutes
99213 15 minutes 20-29 minutes
99214 25 minutes 30-39 minutes
99215 40  minutes 40-54 minutes

*Report 99211 for a minimal problem that may not require the presence of physician or other qualified healthcare professional (e.g., when a physician or other qualified healthcare professional supervises clinical staff who perform the face to-face services of the encounter) which does not have time or MDM requirements.

Specifics of 2021 E/M changes

2. A new MDM table includes clinically-intuitive revisions. In addition, note these important MDM-related changes:

  • Physicians only count problems they actually address during the encounter. This means they can’t simply mention a diagnosis in a problem list or state that another provider is managing it to add to the complexity of the visit. However, please note that providers no longer need to ‘add up’ the number of patient conditions to support a level of Medical Decision Making.
  • Each unique test ordered or reviewed contributes to the amount and complexity of data and overall level of Medical Decision Making.
  • Physicians also get credit for speaking with an independent historian or source (e.g., parent, guardian, surrogate, spouse, or witness, lawyer, caseworker) to obtain a history when the patient is unable to provide a complete or reliable history (e.g., due to developmental stage, dementia, or psychosis) or to coordinate care.

3. CPT code 99201 (level 1 new patient) is deleted based on the same level of Medical Decision Making as CPT 99202.

4. A new prolonged services E/M code (99417/G2212) captures provider time in 15-minute increments and can be used with 99205 and 99215 when time is the basis for code selection.

Forging a path for success

As with all coding changes, documentation can make or break success. The new 2021 E/M Guidelines for Office Services focuses on capturing the provider work in managing patient care. Consider the following:

  1. Clearly identify what tasks were performed on the date of the encounter and for how long. Don’t count services that are separately reported as interpretations. For example, if a physician performs an ECG interpretation and report, they can’t apply that toward the E/M level because separate CPT codes exist (93000, 93005, and 93010) for that element.
  2. Document a medically-appropriate history and/or exam. This is important in terms of demonstrating that the visit was medically necessary and reasonable. Providers can also document that they reviewed and verified information regarding the chief complaint and history that ancillary staff or the patient already recorded.
  3. Clearly describe diagnosis management. For example, identify medication modification, ordering and reviewing each unique test, or documenting the status of a problem and opting to continue with current treatment, including any social determinants of health that affect treatment, and the review of records received from an outside (unique) source. Work with physicians on documenting patient and/or procedure risk prescribed in the patient plan.

Important takeaways

Be sure to ask this question: How does your current documentation stack up against the new E/M guidelines? What are the areas for improvement, and what can you do now to ensure compliance? Provide physician and coder education. Perform internal audits, and close documentation gaps. Create an edit to flag G2212 for manual review to ensure documentation supports services lasting 75 minutes or longer for new patients and 55 minutes or longer for established patients. Finally, review that providers and coders are capturing the appropriate level of Evaluation and Management service based on either Medical Decision Making or Time.  Don’t wait for a payer or auditor to come back and tell you you’ve overbilled or underbilled.

“Understanding the changes and taking the necessary steps to prepare for them will help your team minimize the potential disruption to coding and the resulting revenue integrity.”

It’s also important to ask your EHR vendor what it’s doing to help ensure compliance. For example, how will the EHR’s code calculator incorporate time and MDM? How will it also distinguish between outpatient office visits and other types of E/M services to which the 2021 changes do not apply?

Streamline Health provides Pro-Fee Coding and Audit Services, so our team fully appreciates the impact these changes can have on coding accuracy.  Understanding the changes and taking the necessary steps to prepare for them will help your team minimize the potential disruption to coding and the resulting revenue integrity.

See for Yourself

As more providers are discovering, pre-bill technology is the key to optimizing revenue integrity and financial performance across all service lines. As the leader in solutions to optimize coding accuracy prior to billing, Streamline Health is helping providers establish a new normal that improves their bottom line despite these challenging times. To discover how we can improve coding accuracy and financial performance for your organization, contact Streamline Health today.